Insured claims BCBS wrongfully denied medical claim

Kelly Holleran Dec. 3, 2009, 5:10am

A man has filed suit against his former insurance company, claiming the company was wrong in refusing to pay his claim and in dropping his coverage.

Andrew C. Prusa claims he submitted an application for individual medical coverage on Jan. 27, 2004, to defendant Blue Cross Blue Shield of Illinois. Along with his application, Prusa paid the required $88.43 premium.

Blue Cross Blue Shield granted Prusa coverage on Feb. 4, 2004, and promised to cover up to 80 percent of Prusa's medical expenses after he met his $1,000 deductible, according to the complaint filed Nov. 25 in Madison County Circuit Court.

Throughout his tenure as a Blue Cross Blue Shield insured, Prusa continued to timely make his monthly $88.43 payments, the suit states.

But Blue Cross Blue Shield refused to pay any of the more than $12,000 in medical bills Prusa incurred by December 2005 for treatment to help with his stomach and abdominal pain, the complaint says.

"BCBSIL claimed that questions 9 and 10 of Prusa's application should have been answered 'Yes,' and that additional detailed information should have been included in Section B – 'Details of Health History,'" the suit states. "Further, BCBSIL claims the details regarding question #4 should have included additional information.

"BCBSIL claims the rescission was based on Prusa's Application information concerning his medical history and that 'had his medical information [concerning Prusa's stomach/abdominal pain condition] been available at the time of Mr. Prusa's application, coverage would not have been issued."

But Prusa claims he filled out the application to the best of his ability.

"When completing his Application, Prusa answered all the questions BCBSIL asked pertaining to his medical history and pertaining to the April, 2003 health fair check-up to the best of his knowledge and belief," his suit states. "Prusa's Application neither provided false statements, nor was it submitted with the intent to deceive."

In the three-count suit, Prusa is seeking a reimbursement for his unpaid medical bills, attorneys' fees, statutory damages and other relief the court deems just.

He will be represented by Scott E. Sherman of the Law Office of Scott E. Sherman in Clayton and by Joshua M. Avigad of Kaplan Associates in Clayton.

Madison County Circuit Court case number: 09-L-1286.

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